5.8 Management of Dysphagia for Patients with ABI

The careful management of dysphagia is essential for the successful rehabilitation of acute brain injury patients (Hoppers & Holm, 1999). Ward and Morgan (2001a)  described the use of three distinct types of rehabilitation programs for patients with dysphagia following head injury, based on the status of swallowing function at the time of admission (Winstein, 1983). The non-feeding program was designed as a stimulation program for very low-level patients, in order to prepare them for later feeding (Winstein, 1983). This program includes desensitization techniques, such as stroking, and applying pressure or stretching, to facilitate normal swallowing, sucking and intraoral responses (Winstein 1983).  The second program, the facilitation and feeding program, uses small amounts of puree consistency food to assist normal feeding patterns (Winstein 1983).  The third program is referred to as a progressive feeding program, where specialized techniques were used to help the patient develop swallowing endurance by systematically increasing the amount of oral intake (Winstein 1983).  This progressive feeding program continued until the patient was able to consume a complete meal within thirty minutes without difficulties (Winstein 1983).

For patients who are safe with some form of oral intake, Ward and Morgan (2001b) note that therapeutic strategies utilized in dysphagia management can be divided into two categories: (a) compensatory treatment techniques and (b) therapy techniques (Logemann, 1999).

Compensatory treatment techniques do not involve direct treatment of the swallowing disorder. Their purpose is to reduce or eliminate the dysphagic symptoms and risk of aspiration by altering how swallowing occurs (Logemann, 1999; Logemann, 1991). The types of compensatory strategies include: (a) postural adjustment of the head, neck, and body to modify the dimensions of the pharynx and improve the flow of the bolus; (b) sensory stimulation techniques used to improve sensory input either prior to or during the swallow; (c) food consistency and viscosity alterations; (d) modifying the volume and rate of food/fluid presentation; (e) use of intraoral prosthetics (Logemann, 1999).

Conversely, therapy techniques are designed to alter the swallow physiology (Logemann, 1999). They include range-of-motion and bolus handling tasks to improve neuromuscular control without actually swallowing. They also include swallowing maneuvers that target specific aspects of the pharyngeal stage of the swallow. It was noted that medical and surgical management techniques are included in this category (Logemann, 1999) with these interventions only introduced once trials with more traditional behavioural treatment techniques have proven to be unsuccessful.

Ward and Morgan (2001b) have noted that the efficacy of a large majority of treatments for swallowing disorders have not been studied in the ABI rehabilitation population.  However, many techniques mentioned above have been studied in other adult populations with neurogenic oropharyngeal dysphagia.